Characterization, conservation and loss of dignity at the end-of- life in the emergency department. A qualitative protocol

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

A systematic scoping review on patients' perceptions of dignity

Background

A socioculturally appropriate appreciation of dignity is pivotal to the effective provision of care for dying patients. Yet concepts of dignity remain poorly defined. To address this gap in understanding and enhance dignity conserving end-of-life care, a review of current concepts of dignity is proposed.

Methods

To address its primary research question “How do patients conceive the concept of dignity at the end of life?”, this review appraises regnant concepts and influences of dignity, and evaluates current dignity conserving practices. To enhance accountability, transparency and reproducibility, this review employs the Ring Theory of Personhood (RToP) as its theoretical lens to guide a Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) of patient perspectives of dignity. Three independent teams of reviewers independently analysed included articles from a structured search of PubMed, Embase, PsycINFO, Scopus, CINAHL and Cochrane Databases using thematic and content analyses. The themes and categories identified were compared and combined using the Funnelling Process to create domains that guide the discussion that follows.

Results

Seventy-eight thousand five hundred seventy-five abstracts were identified, 645 articles were reviewed, and 127 articles were included. The three domains identified were definitions of dignity, influences upon perceptions of dignity, and dignity conserving care.

Conclusions

This SSR in SEBA affirms the notion that dignity is intimately entwined with self-concepts of personhood and that effective dignity conserving measures at the end of life must be guided by the patient’s concept of dignity. This SSR in SEBA posits that such personalised culturally sensitive, and timely support of patients, their family and loved ones may be possible through the early and longitudinal application of a RToP based tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01004-4.

Emergent care nurses' perceived self-competence in palliative care and its predictors: A cross-sectional study

AIM

To describe the prevalence of perceived self-competence in palliative care among emergent care nurses, and explore its predictors.

BACKGROUND

Emergent care nurses have a responsibility to develop palliative care competence to enhance the quality of life of dying patients and their families in the emergency department.

METHODS

With a convenience sample, a cross-sectional study was conducted among 415 emergent care nurses from 22 hospitals in China. Descriptive analysis, Spearman correlation analysis, and multivariate linear stepwise regression were performed.

RESULTS

Variables including marital status (single), emergency department not implementing palliative care, no palliative care training, and true cooperation dimension were selected as independent predictors and explained 19.9% of variation in the regression model.

CONCLUSIONS

Interventions to improve healthy work environments, offering palliative care training, advocating for policies in palliative care, and offering support to unmarried nurses can advance nurses' palliative care competence.

IMPLICATIONS FOR NURSING MANAGEMENT

This is the first study of emergent care nurses in China aimed at identifying predictors associated with palliative care self-competence. It is significant in that palliative care training and a cooperative work environment are required to encourage the development of palliative care.

End-of-Life Communication in the Emergency Department: The Emergency Physicians' Perspectives

Introduction:

End-of-life (EOL) conditions are commonly encountered by emergency physicians (EP). We aim to explore EPs’ experience and perspectives toward EOL discussions in acute settings.

Methods:

A qualitative survey was conducted among EPs in three tertiary institutions. Data on demographics, EOL knowledge, conflict management strategies, comfort level, and perceived barriers to EOL discussions were collected. Data analysis was performed using SPSS and SAS.

Results:

Of 63 respondents, 40 (63.5%) were male. Respondents comprised 22 senior residents/registrars, 9 associate consultants, 22 consultants, and 10 senior consultants. The median duration of emergency department practice was 8 (interquartile range: 6–10) years. A majority (79.3%) reported conducting EOL discussions daily to weekly, with most (90.5%) able to obtain general agreement with families and patients regarding goals of care. Top barriers were communications with family/clinicians, lack of understanding of palliative care, and lack of rapport with patients. 38 (60.3%) deferred discussions to other colleagues (e.g., intensivists), 10 (15.9%) involved more family members, and 13 (20.6%) employed a combination of approaches. Physician's comfort level in discussing EOL issues also differed with physician seniority and patient type. There was a positive correlation between the mean general comfort level when discussing EOL and the seniority of the EPs up till consultancy. However, the comfort level dropped among senior consultants as compared to consultants. EPs were most comfortable discussing EOL of patients with a known terminal illness and least comfortable in cases of sudden death.

Conclusions:

Formal training and standardized framework would be useful to enhance the competency of EPs in conducting EOL discussions.